Tag Archives: relationships

Real talk

By Peter Allen December 13, 2021

I love doing couples work. It is endlessly fascinating, usually challenging and often rewarding. It is a privilege and a sacred responsibility to sit in a room with two people who are both bearing their souls to each other with the shared goal of improving their relationship. When I ask couples what their goals are early on in therapy, more often than not, they tell me they wish to communicate better.

At first glance, this seems like an easy task. Many couples who come to counseling have been experiencing a lot of conflict in the relationship, and their communication might typically include yelling, insults or perhaps passive-aggressive statements and various forms of manipulation. It is very tempting to think that if we can teach them to use “I” statements and a calmer tone of voice and to verbalize feelings and perceptions rather than insults, then loving harmony will follow. It is in fact so tempting to believe this that we may ignore much of what we know about human behavior and biology in the pursuit of facilitating these relational improvements.

It is also alluring to believe that helping people improve their communication is largely a data-driven endeavor. In other words, I have information (data) as a counselor that they don’t have, and if I simply impart this information to them, they will “learn” it, and then their relationships will improve. In reality, improving communication is much more process-oriented, which means that being effective involves observing conditions in real time and constantly responding to those dynamics.

I spent far too much time as a professional counselor simply trying to give people the right words to say, and I suspect that many of my colleagues have had a similar experience. But what I have found time and time again is that many of our clients show up to a session perfectly capable of communicating well (and here’s the catch) when they are calm. In my own practice, I have discovered that emotional regulation skills are absolutely integral to good communication. I can have the prettiest, most assertive words in the world for my partner, but if my lid is flipped and I am dysregulated, it will not matter at all.

It merits mentioning that certain qualities and attributes we may wish to develop as human beings really count only when something important is at stake. For example, let’s consider the quality of patience. It is very easy to be patient when we don’t have to wait or when we feel no stress or pressure to get something done. But patience means having the ability to wait with equanimity regardless of what other factors are present. Patience is the quality of not getting upset when you have to wait for something.

Another example is the quality of loyalty. It is the easiest thing in the world to be loyal when you don’t have to sacrifice anything. True loyalty can be known only when something of value is sacrificed to maintain that loyalty. If you want to know who your loyal friends are, become a social pariah and see who still comes to your birthday party. Spoiler alert: That number will be less than 100% of your total friend group.

Techniques must work in real conditions

We understand patience as waiting calmly, regardless of the other factors. We know loyalty to mean that one stands by their friends or co-workers, even when that standing comes at a personal cost, such as missed opportunities or alienation from others. And so shall we know and recognize good communication skills when they are used in moments of difficulty.

This is important to restate and remember: Anyone can communicate well when they are calm, stable, well-fed, comfortable, etc. However, when those conditions are present, we rarely need to practice good communication skills. 

When I work with couples, it is not usually the case that both parties in the room feel completely calm or at ease during the session, because difficult and very personal subjects are routinely discussed. My clients live in the real world, and their relationships are with real, complicated, conflicted human beings. They have children, they have blended families, they have traumatic experiences and upsetting memories, and all of those elements can be front and center in a session. The most important time we need to communicate well is when we are unhappy or insecure or angry or tired because this is exactly when poor communication can create additional problems.

At first, couples will not remember to use “I” statements when they get triggered because using “I” statements requires the prefrontal cortex to be online and operational. If we teach people the right words but not the methods to access those words, then we are in effect placing positive communication habits in a museum, making them something to be observed and admired but not held and utilized. Weaving together the right words and the emotional regulation techniques that allow those words to be accessed is critical to helping couples actually implement positive communication tools in their daily lives — when it counts.

Practice, practice, practice

We also need to help our clients develop a consistent communication skills practice, regardless of variations in their moods and responsibilities. Think of it this way: If you want to get good at shooting free throws, you practice when you’re happy and when you’re sad and when you’re bored. You practice in the sunshine and in the rain. You shoot so many free throws that muscle memory develops and outside conditions no longer play much of a factor in how you set up and take the shot. You control what you can control, and you let go of what you cannot control. That is what makes a great free throw shooter. Becoming a skilled communicator is no different.

When we help our clients develop a practice of positive communication skills in any situation, they become good at positive communication in any situation. Weird, right? When couples are experiencing wonderful times together, we encourage them to share feelings and impressions. We prompt them to recognize and praise their partner’s efforts and to ask for what they need. Just as with any training, the best practice early on is done in low-pressure situations to build confidence. 

Over time, people develop greater skills and habits, and the increased communication provides ongoing context for each partner to observe and consider. And, often, context is the great equalizer in couples therapy. When we know what our partner is experiencing, we are much more likely to consider it and respond compassionately than when we have no idea. 

The more couples practice this in various mood states and settings, the more likely they will be to access these skills when they really need to, during times of great difficulty. We should also encourage them to share feelings, impressions and needs when they are bored, mildly annoyed or at their wits’ end because, well, that’s life sometimes too.

I share this at some point with almost every couple I work with: If you make your partner guess what you need, they will get it wrong. If you tell them what you need, they have the best chance of giving what you need to you. Help your clients develop the practice and habit of asking for what they need, when they need it. This aspect alone will reduce conflict noticeably because so much conflict is centered on partners attempting to ascertain the needs of the other and getting it wrong. 

Conversely, in the absence of any specific dialogue about the needs of the other, it is easy to forget for short or long periods of time that our partner would need anything at all from us. But when our partner shares and we hear what they need, we can respond to that.

Building positive communication habits

There are many ways we can help people integrate these concepts and habits into their lives. Emotional regulation can be as simple as prompting someone to take a few deep breaths while they contemplate what they want to say or asking them to let the weight of their body acquiesce to gravity and simply relax down toward the earth. 

I usually ask people to identify the emotion they are experiencing and see if they can rate its strength on a scale of 1 to 10. We can ask them if they feel any sensations in their body and any associated emotions or thoughts, bringing about mindfulness of their own state prior to communicating. 

I am inviting them to tune in to their own experience and tell me what they are noticing in terms of any conditions that are present. Because if they are noticing things about how they are thinking and feeling, then we know that the prefrontal cortex is working. And all of this is about slowing down and creating some opportunity for self-reflection prior to dialogue. It’s not something we need to overthink; most people will have a sense of when they are functioning well and can communicate well and when they might not be, if we direct their attention toward these factors.

I love using normal cues in the day to prompt practice. Many people eat three meals a day, so they consistently have three natural stopping points in the day to practice some of the skills discussed above. I will say to a client, “How about during lunch today, you praise your spouse for supporting you?” or “Try asking for what you need at dinner tonight, even if it is something small.” 

We could prompt the use of a specific skill at any natural point in a client’s day. And we can encourage clients to be transparent, even telling their partner that they are deliberately practicing skills and would appreciate their support with those efforts (very cleverly practicing two skills at once). Their partner sees them practicing and investing in better communication, and that can be contagious.

I encourage clients to communicate well when they can or to take some time apart and buy themselves some time when they can’t. I have never heard an emotionally regulated person call their partner a harsh name or deliberately insult them in session. I have heard plenty of dysregulated people do that.

At the macro level, we know American culture places a high value on fixing problems, but at the micro level, many of us are less adept at assessing when we lack the proper tools to fix any given problem. At the risk of using too many metaphors in one article, one should not attempt to climb a mountain on an empty stomach or without water. And couples should not attempt to problem-solve serious relationship issues when they are hungry, hurt, exhausted or otherwise low on personal resources. 

When it comes to having conflict with a partner, a persistent myth exists that it is wise and desirable to “hang in there.” Let me state this unequivocally — it isn’t. It is far wiser to disengage, before additional damage is done, than it is to stay in the conversation when it is clear that neither person is giving any ground or understanding the other. 

If my anger is an 8 on a scale of 1 to 10, that is not the best time for me to speak with you. If I want to perform reasonably well, I should probably get my anger down at least to a 4 or a 5 before I re-engage in a discussion. My task is to recognize that in myself ahead of time. Because I cannot wait until I have no feelings whatsoever to communicate, I am always trying to find that sweet spot when I am regulated enough to communicate well. 

This is more important than any particular arrangement of words that we can teach our clients. Part of helping couples improve their communication skills is helping them pick their moments. Just as climbing a mountain should be attempted from a position of confidence and strength, so should problem-solving and conflict resolution flow from this position in couples work.

The important thing for us to keep in mind is that without emotional regulation and consistent practice, attempting to improve communication will be very difficult. Pretty words will not be enough.

Prostock-studio/Shutterstock.com

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Peter Allen is a licensed professional counselor and writer based in Redmond, Oregon. Contact him at peterallenlpc@gmail.com.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Growing percentage of American adults are living single

By Bethany Bray December 1, 2021

A growing share of American adults are living the single life.

The Pew Research Center found that in 2019, 38% of American adults between the ages of 25 and 54 were not married or living with a romantic partner. This number has increased significantly in the past two decades, with only 29% being unpartnered in 1990. While this population includes individuals who are divorced, separated or widowed, an increasing portion have never been married.

The number of married adults fell from 67% to 53% between 1990 and 2019, and the percentage of people who were cohabitating with a partner rose slightly from 4% to 9%. Also, the share of adults who have never been married jumped from 17% to 33% during that time period.

Men are more likely to be unpartnered than women, Pew reports. However, the one exception to this rule is among Black women, with 62% of Black women and 55% of Black men living without a spouse or romantic partner.

Overall, the race and ethnicity breakdown for Americans ages 25 to 54 who were unpartnered in 2019 was as follows:

  • 59% of Black adults
  • 38% of Hispanics
  • 33% of whites
  • 29% of Asians

This evolution of Americans’ living arrangements has also laid bare the financial and other disparities that exist between coupled and single adults. Pew found that adults who live without a partner earn less (on average) than coupled adults, are less likely to finish a bachelor’s degree and are more likely to be financially unstable or unemployed. Single adults’ median salary is $14,000 less than coupled adults, Pew reports.

These statistics create many questions for the counseling profession, including the emotional and relational needs that might arise among single individuals, says Katherine M. Hermann-Turner, an associate professor in the Department of Counseling & Psychology at Tennessee Technological University whose doctoral cognate was in couples and family counseling.

“Many counselors are likely seeing unpartnered clients or family members of unpartnered individuals for services, but what do we know about the stressors of this demographic? … The first step is [for counselors to have an] awareness that this is a growing demographic,” says Hermann-Turner, a past president of the Association for Adult Development and Aging, a division of ACA. “My antenna as a counselor, particularly someone who operates from a systems perspective and relational-cultural theory framework, goes to the potential increased need for emotional connection for unpartnered individuals rather than the economic stressors faced by this demographic.”

In addition to the financial and economic disparities, Pew also found that unpartnered adults were more likely to be living with their parents than adults who are married or cohabitating. Thirty-one percent of unpartnered men and 24% of unpartnered women lived with at least one parent in 2019, which is much higher than that statistic for partnered adults (2% for both men and women).

Hermann-Turner notes that this information raises further questions about what clients who fall into this demographic might need when working with a professional counselor.

“Are these individuals substituting the support of their family of origin for partnership or reliance on external systems of support (i.e., romantic partnership)?,” she asks. “If so, why is this the route for many individuals given the typical complexity of a family system? Is this evidence of an earlier lack of career guidance? Underdeveloped relational skills? If so, how can we as counselors begin to intervene earlier and develop these skills in a younger population? Should we be reconceptualizing family counseling to include an emphasis on adult children and their parents? … I am intentionally avoiding the ‘chicken or egg’ argument and pondering the possibility that enmeshed family systems have intentionally stunted one child’s ability for emotional independence as a way to serve the needs of the parents.”

Olga Strelnikova/Shutterstock.com

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What do you think? How might these demographic shifts affect the work counselors do with clients? How should the profession adapt to help clients and meet their needs?

Add your thoughts in the comment section below.

 

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Read more from the Pew Research Center: https://pewrsr.ch/3DeLtrm

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

When the behavior of others negatively affects clients’ mental health

By Bethany Bray June 1, 2021

In a 1624 devotion, the English poet John Donne argued, “No man is an island, entire of itself; every man is a piece of the continent, a part of the main.” 

This sentiment still rings true in modern-day counseling. Behaviors exhibited by other people in clients’ lives — often the people they love most — can affect them acutely. When these patterns are codependent, manipulative or unhealthy, it can cause clients’ presenting issues to worsen, stall their progress in counseling or otherwise negatively affect their mental health.

Examples run the gamut from an adult client whose parent deals with anxious feelings by being critical of or over-involved in the client’s life to a client whose spouse has experienced past trauma and is prone to angry outbursts.

These types of scenarios are not uncommon, and they often surface as counselors and clients begin to unpack the issue(s) that brought them into therapy, says Jen Ohlund, a licensed associate counselor (LAC) who counsels adolescents and adults at a practice in Mesa, Arizona. One indicator that a client is not getting the support they need from the people in their life can be failure to make progress in counseling, despite hard work on the part of both the client and counselor.

In counseling, a practitioner might hear clients make statements such as “I feel like I’m getting better, but I go home and I keep being told the same [unhealthy] things over and over again” or “I am doing everything I can and nothing is changing,” Ohlund says.

“Any progress they’re making is being shot down by the other individual,” she explains. “That’s when we introduce boundaries. We talk about what a healthy boundary is and equip them with [psychoeducation] that we can’t control how other people react. We can’t always walk on eggshells. Sometimes other people have to work through their triggers, and if they’re not going to do that, we have to set boundaries.”

Fizkes/Shutterstock.com

Seeing the whole picture

Empathic listening and validation from a counselor can serve as important first steps with clients who are wrestling with guilt, aggravation, sadness or other feelings spurred by the behavior of loved ones, Ohlund says. Simply talking through what has and hasn’t been working can be powerful, as can receiving assurance from a counselor that many people struggle with similar challenges and the client is not alone in feeling those same emotions.

“A lot of times, they don’t want to feel this way. They care and love this person,” says Ohlund, a member of the American Counseling Association. “They might feel overwhelmed [or] frustrated with their loved one or turn inward and beat themselves up, feeling like they’re not doing something right [or] not doing enough to meet [the other person’s] needs.”

Counselors can also listen for indicators that clients are struggling with isolation, a lack of boundaries (such as receiving an extremely high number of text messages from a family member) or feelings that they can “never say no” to their loved one. In these cases, clients might not have other people in their life who can act as a sounding board to give them a clear perspective. One way counselors can help clients temper the unhealthy messages they receive from a loved one is to support them in finding connection with other people who offer positivity and a voice of clarity. This will help clients self-regulate, Ohlund notes.

Michelle Fowler, an LAC at the Arizona Center for Marriage and Family Therapy, urges counselors to help these clients through an attachment lens. “We are wired to need one another and respond to one another. Doing therapy in a bubble is very unrealistic,” Fowler says. “The relationships around the client have the greatest influence on their well-being. It’s neglectful of us to ignore those contacts or not address them when they are a source of [a client’s] distress or, potentially, a resource to help in recovery.”

Asking targeted questions during the intake process is a good way for clinicians to get a picture of the supportive factors in a client’s life, says Breanna Lucci, a licensed mental health counselor at a group practice in the North Shore of Massachusetts. These questions can include:

  • Who is in your support system? Who can you turn to for support?
  • Who makes you happy?
  • What are your standards in a relationship, and how do you know a relationship is a healthy one?
  • Does your family know that you’re going to therapy, and are they supportive of that decision?
  • Describe your living environment. Is it supportive?
  • Who (other than your counselor) are you comfortable talking to about topics related to mental health?

Lucci also finds that discussions about a client’s self-talk can uncover outside factors affecting their mental health. She uses motivational interviewing with clients to delve deeper into these external influences.

For example, if a client says, “I’m anxious, but I just need to get over it,” then Lucci, an ACA member, asks, “Why do you feel that way? Where have you heard that?” Or if they say, “I’ve been told I’m stupid,” then she breaks down what “stupid” means to the client and asks, “Who said that? How did it affect you?” Talking through a client’s language choices in this way helps them to recognize patterns and realize how things they have heard from others and internalized have become part of their self-talk and self-belief. The goal of this work, Lucci stresses, is always for the client to get to these realizations on their own.

Carrie E. Collier, a licensed professional counselor who specializes in Bowen family systems theory at her Washington, D.C., practice, agrees that the language clients use in session about their relationships can relay valuable information about the client’s context and how they respond to others.

“An individual is not in a vacuum — there’s always reciprocity in relationships,” says Collier, director of the Bowen Center for the Study of the Family in Washington. “Anxiety is contagious; if a person is living with other people, there are a lot of shared emotions that are going on. I try and help a person get really clear about what’s theirs and what’s the other person’s, and what he or she is putting into it and what [others] are putting into it. … As a counselor, it’s important to see the [client’s] entire context and the landscape. It’s not just one person sitting in the office with me. It’s not a cause and effect. It’s relationships and people reacting to one another, and that is what the counselor and the client are up against.”

Fostering understanding

With those who are surrounded by unhealthy patterns, it is vital for counselors to be aware of resources (both in their local area and online) that can help clients better understand what their loved one is going through and support the client outside of counseling sessions, Lucci says.

As a licensed drug and alcohol counselor, Lucci is knowledgeable about numerous addiction resources in her area, including a recovery center that offers interventions and free family workshops. She often recommends Johann Hari’s TED Talk, titled “Everything you think you
know about addiction is wrong” (see bit.ly/3aqbpV4), to clients whose family members struggle with addiction. She also has a ready list of organizations that offer support groups and other resources to help those whose loved ones live with mental illness or who struggle with parenting issues, caregiving roles, work stress, an incarcerated loved one and a range of other challenges. The support groups and educational materials from the Depression and Bipolar Support Alliance (dbsalliance.org) and the National Alliance on Mental Illness (nami.org) can be particularly helpful, she adds.

Finding avenues of safe support outside of counseling equips this client population to “be healthy in spite of their circumstances, and some of that is [learning] acceptance,” says Fowler, who counsels adolescents, individual adults and couples. Understanding the big picture that frames a loved one’s behavior (including, in some cases, mental illness) empowers clients and can help them “gain empathy or understanding so it doesn’t feel like a personal attack,” Fowler explains. 

Roughly one-third of Fowler’s caseload is adolescents, and for these clients, questions about the adults in their life can reveal important information about the support they are — or aren’t — receiving at home, she says.

“One place that I always start, especially with the adolescents I see, is the assumption that if they could go to the adults in their circle to deal with their [presenting] problem in a supportive way, they probably wouldn’t be in my office,” says Fowler, an ACA member. “Sometimes it turns out the parents have mental health issues and the client is doing as best as can be expected. It is definitely not happening in a vacuum. … If somebody else really is why, or part of why, they are struggling, is that a person who could be involved in therapy? Is this a person who could potentially help, or does the client need coping skills to deal with [this person]? If it’s a parent and child, I definitely want the parent to come in as much as possible. But if that parent isn’t going to be a safe person because they have their own struggles or are not willing to adjust, be open and see [the] child’s perspective, then how do I shore up [the client] with coping strategies?”

One example Fowler has seen among her caseload is clients who identify as LGBTQ and “have gotten very clear messages from their family that they’re not open to talk about it.” These clients are left to work through their identity and mental health issues on their own — an experience she describes as a “personal journey of how to make peace with themselves while staying in their current environment.” 

For couples and individual clients, a dose of honesty from a counselor about how much their situation could improve may be called for, Ohlund notes. “We [counselors] don’t necessarily give advice to clients, but I also think it’s important to be clear that in some situations, if you continue to stay in this relationship, this is what it will look like. If you learn all of these coping skills and boundaries and nothing else changes, the relationship won’t be better. You can maintain the relationship and be stable, but thriving is a completely different thing,” Ohlund says. “It’s important not to be vague. Be very clear [about] what it would look like if they chose different options so they can weigh it appropriately.” 

Even as clients grow through counseling, the other person in the relationship may not change. This concept is so important, Ohlund points out, that it is written into the informed consent forms at the practice where she works.

“This is one of the most difficult parts of therapy: When you grow and develop, the people around you may not,” Ohlund says. “Once [clients] learn coping mechanisms, communication skills and begin to feel more confident … they may find that the relationships around them change, or they may not even want [those relationships] in their life” any longer.

Counselors can serve as vital resources to help these clients work through self-judgment, anger and other feelings, while equipping them with coping mechanisms such as mindfulness, self-care and self-compassion exercises, Ohlund says. She acknowledges that helping clients learn to see things through a new, healthier lens takes time. Along the way, it is important to help clients focus on the things in their life that are going well, she says.

Rewriting unhealthy patterns 

Fowler once worked with a teenage client whose presenting issues were depression, self-harm and suicidal ideation. The client’s parents had gone through a tumultuous divorce seven years prior, and her father had since remarried. The parents had 50-50 custody of the teen and continued to squabble, sometimes in front of her.

The environments at her mother’s and father’s homes were opposite. The only communication she received from her father involved correction or discipline. His home had much stricter expectations around behaviors and schedules than her mother’s home did, and the client also had stepsibling relationships to navigate at her father’s home. Because the client’s friends lived closer to her mother’s home, she had more opportunity and freedom to connect with her peers when staying with her mother.

The teen was “upside down” on whom she could trust, Fowler recalls. She was exhibiting attention-seeking behaviors online and had been hospitalized for suicidal ideation before Fowler’s work with her. 

Fowler took a different approach from the teen’s previous therapist, who had not involved the parents in the counseling sessions. Fowler focused on rewriting the parent-child and parent-to-parent communication and response patterns that had become unhealthy. She also invited the client’s mother, father and stepmother into counseling, first in a group session without the client and later with one of the adults in sessions with the client.

Fowler used emotionally focused therapy with the teen to help her learn to explain what she was feeling to her parents. The method focuses on exploring primary emotions and practicing communication of those emotions in a way that the client’s attachment figure can receive, Fowler explains. By helping the client share — and the parents truly hear what she was saying — the mother and father were better able to understand the seriousness of their daughter’s depression and the impact their discord was having on her. This experience also tapped into her father’s empathy and allowed him to put his anger aside, Fowler recalls.

Fowler also worked with the adults on how to respond to their daughter in helpful and supportive ways. “I explained that [she] is looking for support and safety and is not feeling loved or feeling approved, so she’s looking for it elsewhere,” Fowler says.

The parents agreed to stop arguing in front of the teen, and the father had a change of heart and began to plan activities to be able to spend time with his daughter in a positive way. Within months, the teen was feeling much better, and her self-harm behaviors and suicidal ideation dissipated, Fowler says. Although her parents still have to monitor her cell phone use, the client’s situation has greatly improved.

“All of that contention, seemingly overnight, went away,” Fowler says. “I know that the changes that the parents made were a huge factor in helping the child.”

It “took some convincing” for the father to change, Fowler recalls. His frustration toward his daughter stemmed from feeling that she was being unsafe online and making herself available to strange men. Ultimately, Fowler used those feelings as leverage to explain that he had a chance to be the safe man in his daughter’s life.

“That was the window that helped him see … [and] understand how he had the opportunity [to make] his daughter feel loved,” Fowler says. 

Setting boundaries

Boundary setting is one of the most important coping mechanisms a counselor can provide to clients who are surrounded by unhealthy patterns. Even though clients cannot control a loved one’s behavior, they can control the boundaries they choose to establish in the relationship, Ohlund notes. This work must be client led and will look different for each person, based on their preferences and needs.

Exploration of boundaries is best done in session when the environment is calm — before the client needs to confront a loved one in the heat of the moment. Clients should not set a boundary until they are comfortable enforcing it, Ohlund stresses. The counselor and client should also talk through what it will feel like to enforce the boundary, including understanding and preparing for the possibility that it may make the other person feel worse, including triggering anxiety or feelings of abandonment.

Sometimes people may not understand these new boundaries. “Those who benefit from not having boundaries won’t want to deal with what’s going on with them and are going to fight it a lot,” Ohlund points out.

Ohlund often works with clients to establish boundaries that have stages that are customizable if or when a situation arises. For example, if a client has a spouse or family member who is prone to critical or angry outbursts, the first step might be for the client to leave the room or go to another part of the house. If the behavior continues, the client could leave the house for a brief time. Similarly, they could choose to temporarily block the phone number of a family member who is prone to sending a barrage of text messages when that person is upset.

“This is much better than just asking them to stop. What will you do when [the behavior] doesn’t stop? We have to set a boundary that we have control over so we don’t get sucked in or pulled in,” she says. 

Ohlund once had a client whose mother did not approve of some of the ways he and his partner chose to parent their children. She would repeatedly overstep her bounds and impose her opinions on the children. The situation pitted the client’s children against him, Ohlund says.

The mother continued the behavior even though her son spoke with her about it multiple times. Eventually, with Ohlund’s support, he set a boundary that if his mother continued to disparage his parenting style to his children, he would cut off his family’s contact with her for one month.

The mother did not stop her behavior, so the client followed through and cut off contact. During that time, his mother criticized him to other members of their extended family. “He knew it was the right decision, even though it was tough,” Ohlund says. “Eventually, the mom did come around, although it took a considerable amount of time to come to that point.”

This client’s decision to hold firm to his boundary resulted in a positive outcome, but that isn’t always the case. Sometimes people don’t agree with the boundary, which can create a disconnect or distance in the relationship, Ohlund says. “The reality is that [people] don’t have control over whether someone else is going to respond or not respond. It can be very disheartening and something to grieve and think of as a loss. It’s something you are working very hard on, but it’s out of your control,” she notes.

Collier stresses that the goal of boundary setting should be to guide clients to find what’s best for their own mental health, based on their principles. It also involves reflecting on what has and hasn’t worked in the past.

“The goal is not to get the [other] person to change. That’s very important [to understand]. If you are doing something out of your own principle, then it doesn’t matter how the other person responds. You want to say it to them not because it will help them or prompt change but because it’s your principle. It will only work when the [client] has done their own principled thinking,” Collier says. She advises counselors to ask good questions and stay out of the client’s emotional process: “Don’t jump in and become involved in [a client’s] emotions. Just get them thinking about ways to do things differently.”

Lucci agrees that effective boundaries must be rooted in a client’s values. Part of this process may involve having a wider conversation on what the client’s relationship standards are, including what they want out of the relationship and what they feel is required to continue the relationship.

“Setting boundaries can be extremely uncomfortable for people, and that’s why I emphasize that [boundaries] continually change and can be adjusted,” Lucci says. “[This process] is not one session. It’s a very slow process, and it’s adjust, adjust, adjust.”

Clients who are working to establish boundaries may find it helpful to practice the necessary conversations with a counselor before initiating them with loved ones. For example, what might it feel like not to respond to a text from that person? Collier notes that a counselor can talk this scenario through with a client, acknowledge how hard it will be and assess whether it feels like the right thing to do. “Know that there is going to be an uncomfortableness; saying no is going to be hard,” Collier acknowledges. 

It may also be helpful to focus on communication techniques with these clients, including how to bring up sensitive or triggering topics with a loved one in a nondefensive way, Lucci adds. Counselors and clients can practice taking in comments and information from loved ones and then expressing themselves without spurring debate or becoming defensive. In this vein, Lucci sometimes encourages clients to write a dialogue down and read it back to her in session.

“It’s natural to get really anxious about these conversations, and a counselor can help alleviate some of that anxiety by preparing [with the client],” Lucci explains. She asks clients what the goal of the conversation is and how they want to approach it. “It’s really important to listen to what the client wants,” she says. “I want the client to feel empowered and have knowledge, but ultimately it’s their own decision” regarding how to handle the situation.

The counselor’s role

Counselors play an important role in helping clients whose mental health is negatively affected by the toxic patterns of others in their lives. These patterns may indicate that the other person needs counseling themselves, but first and foremost, the counselor’s ethical duty is to help their client, regardless of whether it is appropriate or possible to involve family members or others in their counseling sessions. (An important caveat is when counselors take measures to protect clients from “serious and foreseeable harm.” See Standard B.2.a. of the 2014 ACA Code of Ethics.)

“It’s not ever my job to diagnose someone I don’t know and those who aren’t a client of mine,” Lucci says. “But I can listen and hear the behaviors described by the client and how it’s affecting them. Then, we focus on how [the client] can deal with those behaviors. I don’t ever want to assume how someone is feeling or what’s going on. … Most of all, I want people to feel connected and come to decisions about change on their own.”

Counselors can also equip clients in these situations with resources and serve as support while they decide what they want the relationship to look like, Ohlund adds. But this work will take patience on the part of the counselor, she notes.

“As a counselor, sometimes we can see really far ahead. We can see really clearly what needs to be done in a situation, but it may take a client a very long time to get there,” Ohlund says. “Sometimes it’s easy to feel frustrated: Why can’t they see [it]? Why do they keep these patterns?” 

She advises counselors to be patient and not feel like they are doing things wrong. Instead, “be assured that you’re doing all you can to support a client, and that’s what they need — they may have never had that in their life,” she says.

Similarly, Collier feels her role is to sit with clients and ask questions to help them explore emotions and come to realizations about their situation. Her focus is on the process rather than the symptoms that bring clients into counseling. “I’m interested in how the person is thinking about the problem and the challenge, what has worked and what hasn’t worked, what they’ve tried and how they understand it,” Collier says.

Counselors also need to work through relationship struggles in their own lives to better support clients who are seeking help for similar issues, Collier stresses.

“The client’s ability to change and really think about their situation is only going to be as good as that person who is sitting in the room with them and their ability to see and think about situations,” Collier says. “Our level of maturity lends itself to what will really help a person, and that comes from really examining relationships and patterns in our own lives. That is above and beyond any technique or anything that I can do with a client. We all have problems in our own lives and our relationships, and we need to work on those so we can help clients and think objectively.”

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Master conflict therapy as a critical component of couples and sex therapy

By Heather Davidson March 4, 2021

“We just don’t communicate well,” Merle reported in our first session while her husband, Luke, nodded quietly in agreement. Like many couples presenting for couples counseling, Merle and Luke believed “communication issues” were causing much of their relationship distress.

As a couples therapist, I knew that “communication issues” could mean myriad things. As is the case with many couples I see, I found that Merle and Luke were actually communicating well with each other. The conflict seemed to have more to do with the fact that they did not like what the other was saying.

The distress that Merle and Luke were experiencing in their relationship was affecting their sexual relationship too. When it comes to couples, whatever issues are going on outside of the bedroom also play out in the bedroom. Recent research shows that 40% to 50% of women (Marita McCabe et al., publishing in The Journal of Sexual Medicine in 2016) and 31% of men (Cleveland Clinic, 2016) experience a sexual disorder. The research suggests that even if couples initially report a nonsexual problem such as communication issues, they are likely experiencing sexual difficulties as well.

Despite how common sexual issues are, many counselors are uncomfortable discussing sexual matters with their clients. Counselors who fail to ask about a couple’s sex life, even in cases in which couples are presenting with the generic complaint of communication issues, are neglecting important information that would help them develop a deeper understanding of the couple. The therapist who disregards the sexual aspect of the couple’s relationship will struggle to help the couple achieve a healthier level of functioning.

As both a couples therapist and certified sex therapist, I believe that a couple’s sexual dynamics can tell us a great deal about their nonsexual dynamics and vice versa. Master conflict therapy has provided me the skill set and ability to go deeper with couples who present with a wide variety of relational and sexual problems.

Identifying the master conflict

Master conflict therapy is an integrative approach to treating couples that combines Freudian psychoanalytic conflict theory and Bowen theory with basic principles and practices of sex therapy. We each have a master conflict and unconsciously choose a long-term partner with the same master conflict. The master conflict stays with us for life, regardless of whether we stay with our long-term partner. The goal of master conflict therapy is for couples to learn how to healthily balance and manage their master conflict, because it will never go away.

A couple typically has the same fight over and over again. While the content of the fight may change, the process of the fight looks the same. For instance, Merle and Luke fought often about how to spend their money, how to spend their free time and even how often they should visit their in-laws. But the process of their fighting was that of two partners vying for the other’s acceptance while simultaneously rejecting each other. The process of the fight can sometimes be a good indicator of what the master conflict is.

Counselors should familiarize themselves with several important facts about master conflicts. First, master conflicts are internalized in childhood by verbal and behavioral messages from one’s family of origin. The master conflict can be influenced by religion, culture, ethnicity or experiences of traumatic events in childhood. Commonly, clients are aware of one side of their conflict, but rarely are they aware of both. Clients might have multiple conflicts, but the master conflict is the most influential or most powerful. In addition, the master conflict is evident is many areas of the client’s life (work dynamics, career choices, friendships, hobbies, etc.). It is also important to note that neither side of the conflict is better than the other. Rather, both sides of the conflict have pros and cons.

Although master conflicts do not influence who we choose for short-term relationships or casual sexual encounters, they do determine the choice of a long-term partner. Long-term partners will share the same master conflict. Master conflicts are normal and exist in every relationship. However, when the conflict becomes unbalanced, the couple will find themselves in distress. Once the master conflict becomes unbalanced, it can be very difficult for the couple to manage. Ultimately, to balance the master conflict, both partners must agree on a strategy and work collaboratively to manage the master conflict.

Many events can unbalance a master conflict, including major career changes, financial changes, a new baby or even living with your partner in quarantine during a global pandemic. For Merle and Luke, problems had been brewing for some time, but the crisis of quarantine unbalanced their master conflict of acceptance vs. rejection. Those with an acceptance versus rejection conflict have one side of themselves that needs to be accepted and another side that needs to be rejected. Merle and Luke both desired to please others and had a strong desire to be accepted by the other. Paradoxically, those with this master conflict also unconsciously set themselves up to be rejected by others.

In our book Master Conflict Therapy: A New Model for Practicing Couples and Sex Therapy, published in 2018, Stephen Betchen and I outline 19 of the most common master conflicts we see in our clinical practices. In addition to acceptance vs. rejection, another very common master conflict that I see is commitment vs. freedom. Clients with this master conflict have one side that wants stability and the security of commitment, but the other side longs to be free of restraints. People who have a history of affairs or a pattern of quickly getting in and out of relationships may be likely to have this master conflict. Clients who witnessed their parents’ affairs or demonstrated lack of commitment to each other may also develop this master conflict. Those with this master conflict may have patterns of changing careers or jobs often, moving frequently or getting involved in many different hobbies or interests without pursuing any of them long term.

Counselors who work extensively with addictions should become familiar with the getting your needs met vs. caretaking master conflict. For this master conflict, one side of the client wants to meet their own personal needs, while the other side desires to be selfless and martyrlike. Clients who have this master conflict often were raised in families in which addiction was present or a parent or sibling had a disability or illness that required most of the family’s attention and resources. These clients often have specific life goals that they would like to achieve, but their martyrdom at work, in friendships, and with their families and significant other consumes most of their time and energy needed to meet these goals.

Another common master conflict is specialness vs. ordinariness. Clients with this master conflict have one side that needs to feel special or different, while the other side feels ordinary or even less than ordinary. The client who builds themselves up while simultaneously putting themselves down could have this conflict. People with this master conflict seek constant validation and pursue materialistic possessions or unique life experiences that they believe make them different. Those with this master conflict are at higher risk of engaging in affairs because affairs are an easy way to experience the high of being “special.” Despite the constant chasing to set themselves apart from the crowd, people with this master conflict continue to feel as though they are “less than” or just ordinary, often because what they have built their specialness up from is not authentic.

Counselors who work with high achievers, including those at the top of their professional fields, celebrities and elite athletes, should look out for success vs. sabotage. Clients with this master conflict want to be successful or big and often have achieved something major, but the other side of themselves desires to be small or to fail. With great success comes the risk of great failure. Individuals with this conflict will sabotage their own success, and because their partner shares the same master conflict, their partner will also sabotage them if they become too big or too successful. 

Assessment and development of relationship symptoms

The first three to five sessions should serve as the assessment phase of treatment. While I let couples start where they need to in the first session, during the next few sessions I collect a genogram and history for each partner. As I gather this information, I also pay attention to both the language they use to describe their presenting problems and to their nonverbal communication.

Merle often used the word “rejected” and described her position in the relationship as “unfair.” She tended to be the more vocal and active partner in couples therapy. Luke, on the other hand, presented as distant and seemed shut down or dismissive toward Merle. Luke reported that “Merle just does not like what I value,” and I observed resentment in many of the passive-aggressive comments he would make toward Merle in session.

The couple explained that they were seeking couples therapy because of “bad fighting and poor communication” since being quarantined with each other. Some of the fights were related to sharing household tasks and parenting while still trying to work. But the major source of conflict concerned whether now was an appropriate time to try having a second child. Luke believed the couple should delay or not even have a second child because of the economic instability associated with the global pandemic. Merle accused Luke of being “selfish” and concerned merely with having time to pursue his artistic interest (an interest with which he was experiencing success).

The couple reported meeting as young 20-somethings at work. They both described the dating and engagement phase of their relationship as positive. At the time, Merle was supportive of Luke pursuing art, and in turn he supported Merle going after her dream career even though it was in a low-paying field. Although the young couple had always planned on having a family eventually, they were surprised to learn a few months before their wedding that Merle was pregnant. They both cited the unplanned pregnancy as the beginning of their relationship’s demise, but they each had different beliefs as to why that was.

Merle came from a warm but intrusive family. She described having close relationships with her sisters. She had excelled in school and sports as a child and teen. Merle described herself as a “people pleaser,” and she often worried about disappointing her family and friends. When one of her sisters dropped out of college to pursue a different career path, Merle saw her parents struggle deeply with that decision. Merle’s father was a first-generation immigrant who had never had the opportunity to go to college. It was very important to him that all of his daughters complete college, and Merle believed that he never fully recovered from her sister’s decision to leave school.

When Merle discovered she was pregnant before her wedding, she was so terrified to disappoint her parents that she concealed the news until after the event was over, even though it was obvious that she had gained weight. As Merle explained, “I would rather deal with my parents’ disappointment about me getting fat than their disappointment in me getting pregnant before being married.”

Luke came from a disorganized and controlling family. Both of his parents came from working-class backgrounds and were religiously conservative. Although Luke had an interest in pursuing the arts, both of his parents prohibited him from getting involved in such an “impractical” interest and pushed him into activities that were “better for getting into college,” even though he had little interest in them. Luke was also deaf in one ear, which had created learning difficulties for him as a young child. This was another trait he felt made him “less than” his other siblings. While his siblings followed in the path of their religious parents, Luke showed little interest in organized religion and eventually left his parents’ faith as a young adult. This decision caused much conflict within the family.

As the third child of seven, Luke had often witnessed his mother being overwhelmed by their large family, especially given that her husband worked long hours to support them. Luke described feeling robbed of what he perceived to be normal childhood pleasures and experiences due to his parents’ inability to provide adequate attention and financial support to their children.

Luke had spent much of his 20s getting his professional day job to a place where he was secure and could devote more time to pursuing his artistic interests, which his parents continued to disapprove of from a distance. Although Merle tried to reassure Luke that their baby would not change his ability to engage in his artistic pursuits, he knew from his own childhood that this simply was not true. Luke described a period of depression during the pregnancy. Merle reported being excited about the pregnancy but also stressed about how to “make Luke be OK with it.”

During the assessment, I always take a sexual history. In this case, both partners denied experiencing any sexual trauma, and both reported having long-term relationship partners before they met each other. Luke acknowledged being less sexually experienced than Merle due to his upbringing. Despite this, the couple felt positive about their sexual relationship before having a child; they were both happy with the frequency and believed they shared mutually in pleasure. In recent years, however, their sexual frequency had declined. Luke attributed this to stress, whereas Merle worried that it was more personal.

Discussing a couple’s sexual development and history helps the counselor to recognize sexual patterns. It also helps the couple become more comfortable talking about sex. Merle eventually disclosed tearfully that she worried Luke was no longer attracted to her because he experienced delayed ejaculation. Luke claimed to be unsure about why he was experiencing this problem and denied that he was no longer attracted to Merle. Both reported that the delayed ejaculation began around the same time they were fighting over whether to have a second child.

In treatment, Luke eventually admitted feeling conflicted about having a second child and worried that the additional demands would take away from his pursuit of a side career as an artist. Merle dismissed his concerns as selfish and lashed out at him for “taking away” her dreams of a larger family. Living under quarantine caused Luke rarely to have time to do anything with his art. In fact, he spent most of his time balancing working from home and trying to parent. The result of these sexual experiences left both partners feeling rejected by the other: Merle by Luke’s delayed ejaculation and lack of desire for another child, and Luke by Merle’s reaction to his sexual difficulty and overly optimistic stance on having another child.   

Treatment and relapse prevention

Master conflict therapy consists of four treatment goals:

1) To help the couple uncover their shared master conflict

2) To help the couple determine the origin of their master conflict

3) To help the couple decide which side of the conflict to choose, or to integrate both sides of the conflict to a tolerable, balanced state

4) To alleviate the couple’s symptoms, both sexual and nonsexual

Couples should leave treatment knowing how to manage their master conflict, which will prevent a relapse when their conflict becomes unbalanced in the future. Their fighting should become less intense and less frequent, and they should have the skills to collaboratively manage their master conflict.

It takes many sessions to fully understand a couple and to gather enough data to support whatever master conflict a therapist might suspect. During this time, the therapist should be conducting a thorough assessment, providing the couple with relevant psychoeducation regarding their presenting problem, and providing the couple with behavioral strategies that can help them get out of crisis.

With Merle and Luke, I discussed psychoeducation regarding delayed ejaculation and sexual desire. I also helped the couple improve their basic communication skills. Because Luke did not have any medical risk factors that would have caused delayed ejaculation (we ruled these out with an extensive medical history, a visit to a urologist and routine bloodwork), I suspected most of the problem was psychological. I also explored with the couple the behaviors and emotional baggage that each of them brought to the relationship from their families of origin that not only informed their conflict style, but also colored the way each of them viewed this conflict.

Merle and Luke soon began to see the ways in which they were similar, including both never feeling fully accepted by their families and both fearing rejection by the other. They eventually recognized the ways that their own acceptance vs. rejection master conflict played out in other areas of their life unrelated to their romantic relationship. Merle had a long history of people pleasing and a yearning to be accepted by female friends; this often set her up for disappointment and rejection. Luke was a hard worker and longed to be acknowledged at work, but when he did receive praise, he would act out, leading his superiors to feel frustrated with him. Discovering how similar they were to each other helped Merle and Luke to build mutual empathy.

Once this couple gained a better understanding of their master conflict and the impact it had on their lives, we turned to the issue of having a second child. Merle felt conflicted between wanting to please Luke by limiting the family to one child and wanting to expand the family, even if this meant additional challenges for them and more tension between them. Luke saw Merle as willing to risk their relationship, their financial stability and the overall stability they had created for their first child just to have another child. He explained that he worked hard in a day job that he did not particularly like and put his artistic pursuits to the side for the sake of family stability. This had also enabled Merle to take her “dream job” even though it was low paying — something the couple agreed on during their engagement.

After much processing, Luke expressed that the only way he would agree to having a second child would be if Merle took a higher paying job or they found a way to move to a much more affordable area of the country. Faced with the idea of losing her career, Merle was better able to resonate with Luke’s position. Ultimately, the couple decided to shelve the decision to have another child for one year. Merle would explore other career opportunities that could provide the family with additional financial security, while Luke agreed to look for affordable places that the family could live and examine whether a more permanent work-from-home situation might ever be available to him.

Upon termination, the couple reported fighting much less frequently and with less intensity. They reached an understanding of their master conflict and could now easily predict where each of them might struggle or feel triggered by the other. As they had resolved their conflicts, gained more understanding over their pattern of fighting and mutually agreed not to have another child at this time, Luke’s delayed ejaculation subsided. Merle’s fears of not being attractive to Luke waned, and the couple both reported feeling more emotionally and sexually connected.

Master conflict therapy prepares couples to manage their differences and conflicts for the long term. By providing a framework for better understanding themselves and each other, the couple can better manage future conflicts — regardless of the content — as they see how the process is the same.

 

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Heather Davidson is a licensed professional counselor and the founder/owner of a boutique private practice in Bryn Mawr, Pennsylvania, called Better Being Main Line. She is both a certified sex therapist and a certified eye movement desensitization and reprocessing therapist and specializes in treating individuals and couples with sexual issues and those with traumatic experiences. She is the co-author of the book Master Conflict Therapy: A New Model for Practicing Couples and Sex Therapy (Routledge, 2018) and is an instructor for the Council for Relationships’ postgraduate certificate program in sex therapy. Contact her at heatherdavidsonlpc@gmail.com.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Gone but not missed: When grief is complex

By Bethany Bray January 27, 2021

The aphorism “do not speak ill of the dead” is attributed to the philosopher Chilon of Sparta. First written in Greek and later popularized in Latin, De mortuis nihil nisi bonum, the phrase perpetuates a social taboo against criticizing someone who has died.

Centuries after it was first uttered, clients in counseling may still hesitate to “speak ill” of someone in their life who has died. It’s natural, however, for human grief to involve a range of thoughts and feelings — not all of which will frame the deceased in a positive light. This is all the more true when the person who died had an abusive, rocky, strained, unsupportive, toxic or absent relationship with the client.

“Having conflicted feelings about the deceased happens more often than is discussed,” says Elizabeth Crunk, a licensed graduate professional counselor who specializes in helping clients with grief and loss at her private practice in Washington, D.C. “There’s a societal expectation that we don’t speak ill of the dead, and I think that sometimes can keep people even from seeking counseling.”

That hesitancy can be compounded when the client is worried about how a counselor might react to their situation. It isn’t uncommon for clients to assume that a practitioner will judge them negatively or expect them to forgive the deceased if they are struggling with mixed feelings about the person’s death, Crunk explains.

“It’s important [for counselors] to validate those coexisting feelings. It is possible to feel both sorrow and joy,” Crunk says. “Also, it’s important to validate [a client’s] feelings of numbness or not feeling sad. Assure them that they don’t necessarily need to conjure up sadness if that’s not genuinely what they feel.”

It’s complicated

The emotions that clients experience in response to the death of a person with whom they had an unhealthy relationship are certainly complicated. However, the term complicated grief is a specific psychological diagnosis (also called prolonged grief disorder) that involves lengthy, extended grief that often is accompanied by intense emotional pain and longing for the deceased, as well as maladaptive behaviors such as disbelief that the person actually died. (For more, see our 2014 article “The complicated mourner.”)

It is possible that clients who have lost someone for whom they have mixed feelings will experience complicated grief. However, Crunk says, the experience is perhaps more likely to fall under the definition of disenfranchised grief — a type of grief that is unsupported or unrecognized by society or culture.

Clients who don’t feel “sad” in the traditional sense about a death may believe that their experience is not socially acceptable. Such mixed feelings can be especially common when the death has a certain stigma attached to it, such as with deaths due to suicide or drug overdose, says Karin Murphy, a licensed professional counselor (LPC) who specializes in grief work at her Doylestown, Pennsylvania, private practice. Counselors who work in the addictions field or with clients whose loved ones battle addiction may hear clients disclose these types of feelings, she notes. Regardless of specialty, counselors may encounter clients using language that minimizes their loss (even when they feel the loss acutely) if they sense any stigma connected to the person’s death.

“It’s really important for counselors not to perpetuate that disenfranchisement. [A client’s grief] is supported, recognized and valid,” Murphy says.

The disenfranchised grief these clients experience “doesn’t allow room for them to express the range of what they’re feeling — especially relief,” adds Crunk, a member of the American Counseling Association and a courtesy assistant professor in the counseling department at George Washington University in Washington, D.C.

Such circumstances can spur conflict even within family networks, Crunk says. One or more family members may have had a good and loving relationship with the deceased, whereas other members of the family may not have. In these cases, family discussions about how, or whether, to memorialize and remember the deceased can be fraught with tension.

The death of a parent, spouse or other person who was abusive, neglectful or invalidating toward a client can result in a grief process that is difficult for others to understand or accept, says Mark Tichon, an LPC who is an associate professor and counseling program director at Lincoln Memorial University in Tennessee.

“The relief that can accompany the passing of an abuser is hard to discuss without seeming callous,” says Tichon, a member of ACA. “In these cases, strong contradictory feelings of longing for a [healthy] relationship and the burden of guilt at the sense of relief may result in a grieving process that is marginalized and not socially validated.”

Related emotions

Clients who seek counseling for a range of issues could be struggling with this type of unprocessed grief without being able to name it or disclose it themselves at intake. Counselor clinicians can listen and watch for a number of emotions that commonly dovetail with struggles over the loss of a person for whom the client had a complicated or unhealthy relationship.

In Murphy’s experience, shame, relief and guilt are most commonly expressed by these clients. Feeling a sense of relief that a person is gone often causes clients to question what that means about them.

“It’s feeling release, but [clients] have a very difficult time naming that. ‘What does that say about me if I’m relieved that this person has died?’ And with that relief comes shame,” Murphy says. Clients may struggle with, “What’s my part in this? What did I do to contribute to this sense of unfinished business? And the would haves, could haves, should haves that come from that.”

In addition, Crunk notes that these clients may express self-blame, anger, numbness or ambivalence over the loss. They may grapple with feeling unsettled or unresolved about certain aspects of their relationship with the deceased. They may feel grief centered not on the loss of the actual person but on the loss of a relationship that never was or of what might have been, Crunk adds.

Murphy urges counselors to remember that complicated feelings can also occur when clients experience nondeath losses, such as a change in someone who is no longer themselves because of dementia, addiction, chronic illness or other conditions. A conflicted relationship does not go away when the person begins to change because of illness, she points out. In fact, clients’ emotions may be exacerbated if they are pushed into a caregiving role.

“Understand that loss may not involve death. Life is really a series of losses, but a lot of times we don’t think about grieving, or giving ourselves permission to grieve, unless there’s been an actual death of a person,” says Murphy, who is certified in thanatology and has past experience as a hospice bereavement coordinator. “A lot of times, we have feelings about things, but we’re not really told or given space to understand that not only is it OK to feel that way, but we might expect to feel that way. That’s where the disconnect happens — feeling too much or too little. And that’s what brings [people] into counseling.”

In session, Crunk begins to explore the client’s feelings surrounding their loss with questions about the relationship the client had with the deceased. She asks the client to describe what life with the person was like. If there is any indication of conflicted feelings on the part of the client, she follows up with more gentle questioning.

“I ask them early on to talk about their relationship with the person [who died]. I try to open the door a little bit for them to share if there is some ambivalence. I don’t want to push that too hard but [simply] open the door. I want to assure them that they don’t have to speak positively all of the time,” Crunk says. “Even with deceased loved ones that we had a good relationship with, there are always aspects that we didn’t like, or things we didn’t agree with. I always try and leave room for that side of the coin.”

“Sometimes what comes up too is that we start our work and the client thinks that they had a pretty positive relationship [with the deceased], but as we begin to dig deeper into the story, other more complicated aspects arise,” adds Crunk, who co-authored a 2017 Journal of Counseling & Development article, “Complicated Grief: An Evolving Theoretical Landscape,” with Laurie A. Burke and E. H. Mike Robinson III.

This was the case with one of Crunk’s clients who grew up with a mother who was abusive. In counseling, the client needed help processing the death of her father. At first, the client identified her father as a protective figure, but as she worked through the loss in counseling, she began to voice feelings of disappointment that her father hadn’t done more to remove her from an abusive situation. At that point, Crunk recalls, their counseling work shifted to processing the client’s newly discovered feelings about her father.

Grief has many layers, but that is especially so for clients who have conflicted feelings, Tichon says. “One thing clients may need to do with a compassionate and humanistic counselor is grieve the loss of having an ideal parent, for which many clients hold hope as they grow older, or grieve the loss of hoped for reconciliation that will never come.”

Tichon once worked with a man who struggled acutely with the loss of what could have been. The client’s father, who had narcissistic personality traits, died “just as their relationship was starting to become more of an adult friendship where [the son] could exert healthy boundaries that allowed him to genuinely enjoy their time together,” Tichon says. The client’s father had died suddenly, so there was no chance to say goodbye or find closure.

“It took a long time for him to reconcile the conflicting emotions of sadness over the death of his father with the feeling of freedom from parental judgment and punitive emotions,” Tichon says. “One key goal of therapy was for this client to resolve feelings of guilt over the relief that his dad was no longer in his life. At the end of our time together, this client was able to say thoughtfully, ‘I still miss him, but I’m also relieved he’s out of my everyday life for good’ with a sense of peace.

“The tension between feelings of loss over what could have been a meaningful adult relationship, anger and resentment over emotional neglect during his childhood and adolescence, and guilt over feelings of relief that the relationship was finally over had resolved to … greater clarity and peace as he became more fully accepting of these intense and contradictory feelings.”

Unwrapping

Grief work should always be tailored to the specific needs of the client, but that becomes especially important with those who are navigating mixed emotions about the deceased. As a counselor who specializes in grief and loss, Crunk may have five clients who are experiencing the same type of loss — the death of a parent, for example. But as Crunk points out, each client will have different aspects of the loss that they struggle with and need to process.

To narrow the focus, Crunk encourages clients to identify what is “most troubling” to them about the loss. If the loss was traumatic or unexpected, that may be the aspect that is most troubling to them, she explains. But for other clients, it could be feelings of guilt or shame surrounding a person’s death.

One of Crunk’s clients was mourning the loss of her grandchild. The client had experienced a troubled upbringing herself, but as an adult, she had endeavored to create healthy and safe family dynamics for her own children and grandchildren. As their work in counseling progressed, it became clear that the client was grieving the loss of her identity as a loving grandparent as much as the death of her grandchild.

“I had assumed that losing her first grandchild was the worst of it. But when I asked her what was the most painful, she said, ‘I worked really hard to cultivate a healthy, stable life, and now I’ll never have that perfect life.’ She had lost that part of her narrative: She no longer had a ‘perfect’ life,” Crunk recalls. “It’s important [for counselors] to put personal assumptions aside. What you assume is the most troubling [aspect] may not be. Let the client dictate, and spend the most time on that.”

Helping clients give voice to the complicated feelings that accompany a loss is among the most important things that a counselor can do, says Tichon, who is scheduled to co-present a session, “Complicated Grief: Treatment Stories and Experiential Exercises,” at ACA’s Virtual Conference Experience in April. Tichon has past experience as a geriatric counselor and would sometimes hear clients express a range of feelings that they had held on to for years regarding a loss.

One client, a woman in her 80s, had lost her husband two decades prior but still harbored resentment because he had been emotionally punitive, controlling and physically abusive early in their marriage. In counseling, she needed to process both the loss of her husband and the pain he had caused her.

“She grew up in an era when people often did not discuss their marital problems outside of the home. At the beginning of addressing this topic in therapy, she had a lot of guilt and shame about ‘talking bad about him,’ as she had some religiosity about needing to honor her husband,” Tichon recalls.

As their counseling work progressed, the client grew in her ability to verbalize her feelings of hurt and sadness and, in turn, process the abuse her husband had perpetrated. Only then was she able to focus on some of the more positive feelings she had toward her husband, Tichon says. As a result, her depressive symptoms lessened, and her life narrative became much more positive.

“He had been dead for 20 years, but her unexpressed resentment had [been] pent up in her all those years. … She made a breakthrough in the process of grief when she was able to voice that although the physical abuse had ended when she was in her 30s, she held contempt and emotional distance [for her husband] through the end of the marriage. At 83 years old, she wound up owning her own part in a bad marriage, and in a faith-based, spiritual way, asked for forgiveness for not accepting his remorse and validating that, in some ways, he was a changed man [while] he was still alive,” Tichon says. “In short, grief needs to happen, and when we allow the depth of the process to work through in what is often long-term therapy, we deeply heal.”

Making meaning

Expressive therapies can be particularly useful in helping clients make meaning of losses that involve mixed feelings. Exercises such as writing a letter to the deceased can be especially helpful when clients feel that things were left unfinished or unhealed in the relationship. However, work should be client led, and interventions must be used only when appropriate.

“Writing a letter to the deceased person — highlighting the happy moments, the resentment, anger and sadness that the relationship caused, and unrealized dreams and hopes — and reading that letter using empty chair work can help integrate these emotions into the personality,” Tichon says. “I find that when using the empty chair technique, if I have the client mindfully visualize the person sitting there, down to remembering mannerisms and clothing of the object of their grief, it makes the experience particularly impactful. I would rule out this depth of visualization, however, if the deceased was particularly abusive. I would not engage the client in this level of visualization of the abuser, as the intervention is significantly deep. In cases like this, venting strong emotions and giving voice to unresolved anger and hurt is, in itself, very cathartic.”

Bernadette Joy Graham, an LPC who specializes in grief and loss at her Maumee, Ohio, private practice, uses a similar technique, prompting clients to use their imagination to create a space where they can visualize meeting the person who died and speak with them to find closure. This can be a real place, such as a room in their childhood home, or a setting that holds meaning for the client. Graham lost her mother when she was a teenager, and she uses this technique herself, imagining a front porch where she can sit down with, see and speak with her mother whenever she feels the need to.

Crunk also uses various correspondence exercises, including letter writing, journaling, the empty chair technique and other imagined dialogue techniques, with her clients. She says this work allows clients to say things they wish they had said while the person was still alive, apologize if they feel that is needed, work through complicated emotions and process unresolved conflict.

“The end goal is about revising their self-narrative and their narrative of the relationship with that person that brings a little more repair and helps things feel a little bit more integrated,” Crunk says. “I use a lot of attachment-informed meaning reconstruction techniques to help them create a coherent grief narrative.”

In sessions, she also looks for nonverbal cues that might indicate that a client needs to explore something further. If a client shows signs of agitation, for example, she’ll ask them to name what they’re feeling.

“If I see tears, I ask, ‘If these tears could talk to you, what would they be saying?’ If they say, ‘I feel a heaviness in my chest when I talk about this person,’ I might ask them to put a hand on their heart, and I might mirror that with my own hand,” Crunk says. “Then, I’ll ask them to describe that heaviness. Does it have a shape? Does it have an image? It’s all with an aim of them being able to tolerate that.”

Crunk is using telebehavioral health with her entire caseload during the coronavirus pandemic and acknowledges that picking up on nonverbal cues from clients can be more challenging. However, she believes that “it’s all the more important to show that I’m present, that I’m there with them, offering a place to cry or feel anger or relief, whatever it is.”

Some grief counseling techniques may need to be adjusted slightly when used with clients who did not have a good relationship with the deceased, Crunk notes. This is the case with empty chair, letter writing and other expressive techniques. The goal of these techniques is not to have clients reimagine their narratives regarding the person — for example, by pretending that the abuse never took place or that the person never lapsed into addictive behaviors. Rather, the goal is to help them reconstruct their narrative of their relationship with that person and, potentially, accommodate any new insights about the person who died or their relationship with that person into their current awareness or schemas. Sometimes, Crunk explains, when “conversing” with the person who died, the client stumbles upon a new insight about that person or their life that helps the client see their relationship with that person from a different perspective — one that can potentially help the client make more sense of their loss or bring them some calm.

These techniques are meant to offer clients a pathway “to revise the relationship in a way that they can carry it with them but that does not put pressure on the client to transform it into something that is unrealistic or fictional,” Crunk explains. “It helps the client imagine a world where there is an opportunity to receive an apology or hear words that they yearned to hear the person say.”

Clients sometimes express doubt about whether the deceased person loved them or struggle with things that went unsaid or undone while the person was alive, Murphy notes. She urges counselors to help clients find creative ways of expressing or completing what was “left undone.” For instance, counselors can leverage anything that a client enjoys as a hobby — writing poetry, painting, making collages — to help them communicate thoughts that are uncomfortable or to explore things that went unfinished between themselves and the deceased.

The simple act of writing down a thought, even if it gets tucked away in a desk drawer or journal, validates what the client is feeling and acknowledges that they are working through it, Murphy says. She sometimes recommends that clients read licensed mental health counselor Stephanie Jose’s book Progressing Through Grief: Guided Exercises to Understand Your Emotions and Recover From Loss, which features journal prompts throughout the text.

“Getting the thoughts and feelings out of your head and having a container for them is going to bring relief. It allows clients to process these feelings but also separate themselves from them and put them in a separate place than their mind,” Murphy says. “There is a common misconception: If I just give it enough time, I’m going to feel better. In reality, it’s time plus what you do that will help.”

In addition to encouraging expressive therapies, Murphy often suggests that clients seek out grief support groups so that they can connect with others going through similar experiences. Doing volunteer work can sometimes help clients address things that they feel they didn’t accomplish with the person who died, she adds. For example, they may not have been able to reconcile with an older relative before that person passed away, but they can forge connections with other older adults by volunteering at a nursing home or similar setting.

Similarly, counselors can help clients create new rituals to mark the passing of someone for whom they have mixed feelings. This can be done privately on their own, or with the practitioner in session. It can involve anything from making a donation to a cause that is important to the client or was important to the deceased, to eating at a restaurant that the client associates with good memories about the deceased.

Tichon agrees that expressive and creative therapies can be particularly helpful with clients who are “stuck” or need to process hurtful feelings regarding a loss. In one technique, Tichon has clients rip off a piece of paper for each emotion or painful memory that they express in session regarding the deceased.

“At the end of this exercise, the client is often in tears and staring at a shredded pile of paper, deeply in tune with the feelings of pain and brokenness. We then process how this piece of paper won’t look like what it did before we started, but we can use it to build something new. And in grief, things won’t be the same [either], but they can be good again,” Tichon says.

Tichon then directs clients to take their shreds of paper home and use them to create something that speaks to their hopes for the future. “This has been a particularly powerful experiential intervention, and clients have brought back art and murals that serve as metaphors for moving forward and building new meaning in life,” he says.

Leaning in

Counselors might find themselves experiencing the urge to comfort clients who are struggling with difficult emotions related to the death of someone who inflicted pain upon them, Crunk notes. While these clients need support, they also need to gradually work through the discomfort they feel regarding the loss.

“Grief, as painful as it is, it’s my belief that it needs to be felt. It can become complicated, but in general, for the vast majority of people, it’s not a disorder. [It’s] an emotion that needs to be felt and honored. I try and create a space for the person to emote and hold that grief [in a] container for them. I don’t want to press too hard, but I encourage them to lean in to it, to be able to expand their tolerance and sit with their grief,” Crunk says. “It’s a delicate balance because, as much as I want to provide comfort, if that’s all that I do, then nothing will change. … We want so badly to help [our clients] and provide support and comfort. It can feel counterintuitive in grief counseling, but sometimes the most helpful thing to do is to help them increase that capacity to feel their grief. As painful as it is, it’s a necessary part of healing.”

That delicate balance involves helping clients access and sit with their feelings of grief and find ways to take respite from their grief, pursue restoration or give themselves permission to feel positive emotions, Crunk adds.

Clients who are struggling with a painful, complicated loss sometimes ask how soon they will feel better or get through it. Making promises to these clients that everything will eventually be fine is not appropriate, Graham asserts. Although it is natural for counselors to want to “fix” these clients, practitioners must push back against that urge, she says.

“Be honest with the client and say, ‘This will never be easy, and you might never have [complete] closure,’” Graham advises. “I give them as much support as possible, but I never say, ‘It’s going to be OK.’ I say, ‘I don’t know how long this will take. Everyone’s different and everyone’s unique. There is commonality in grief, but no two experiences are the same.’”

Murphy acts as a gentle guide for clients as they lean in to their uncomfortable feelings related to grief. “I often tell clients, ‘We’re doing this in bite-size pieces … because it’s too big to do all at once.’ I hear this a lot from my clients: ‘It’s been three months, and no one wants to hear me talk about this [anymore]. Why aren’t I over it?’ A lot of [this] is realizing that grief has no timeline.”

Murphy says clients often need to give themselves the following permission: “I have every right to grieve this. It matters to me, and it’s going to take as long as it takes.”

Instilling self-compassion and focusing on self-talk can make an important difference for clients struggling with disenfranchised grief, she says. “Finding the self-compassion to sit with what you need to allows you to move past it,” Murphy says. “I often hear from clients, ‘If I let myself cry, I’m never going to stop.’ I [say to clients], ‘Let’s test that out. When was a time when you allowed yourself to feel something, and did that last forever?’ It’s a lesson that feelings come and go, but they’re not here to stay.”

Forgiveness and compassion

Clients who harbor feelings that go against cultural norms — such as feeling relief that a family member has died — need a safe space to voice those feelings. Tichon urges counselors to “wear their best Carl Rogers hat” when working with these clients and to remember the principle of unconditional positive regard.

“Allowing the client to experience the full range of conflicting emotions, and providing the depth of a supportive, nurturing and nonjudgmental environment — which the client often has not experienced — can allow deep healing to occur. … Clients may have feelings of longing and sadness, but also betrayal, anger and contempt. It is helpful to extend compassion and allow clients to explore and express the fullness of those conflicting emotions and grieve the loss of the ideal parent, spouse or significant attachment figure who they never had. [This can result] in validation of feelings [that are] contrary to cultural messages on grieving.”

Murphy also emphasizes the need for practitioner compassion with these clients. “Maybe they’ve never had anyone ask them how they’ve felt about the loss. That can go a long way, and it opens the door to get them to talk about it,” Murphy says. “Validation [of the client’s feelings] is the important first step.”

“A big concern [that clients voice] is ‘What’s wrong with me? Why am I feeling this, and why can’t I get over this?’ And the answer is because you’re human,” Murphy continues. “When we’re doing this type of work, the relationship — that therapeutic alliance — is the most important. We can talk about tools, but the most important thing is that the person is feeling heard and acknowledged. … What we [counselors] can bring is to be present during that pain and allow the space [to process it]. That’s what it’s all about: Just being validated is the most important thing, and then figuring out from there what tools are needed, because it’s so individualized.”

Graham says that “empathy goes a long way” with these clients and also stresses the need to keep the work client led. Prior to intake, she explains to clients that the assessment process will take the entire session and that she will be asking about subjects that may stir up difficult feelings. “Don’t assume that they know what assessment is and how it works,” Graham says. “They may not realize that they’re going to have to disclose past trauma, assault” or other painful issues.

A gentle approach on the part of the counselor can prevent clients’ anxiety from spiraling, Graham says, especially if they aren’t familiar with the therapy setting. This can mean the difference between a client returning to counseling or dropping out, she says. “I tell the client, ‘There will be a lot of serious questions that are going to take you back in time. If it gets too emotional, we can stop and take a break,’” says Graham, who previously worked at an inpatient rehabilitation center for clients with substance dependence. Graham also stays mindful during sessions and steers the conversation to lighter topics toward the end, while leaving time for questions from the client. If appropriate, she finishes with a joke to get the client laughing. “They are going to have to go home and function [after session],” Graham says, “[so] I try and close the wound back up a little.”

Another aspect of this work with which counselors must tread lightly is the issue of forgiving the deceased, Crunk says. This too must be client led. Forgiveness is sometimes an outcome of grief counseling, but it should never be imposed by a counselor, she stresses.

“I would never pressure a client or use that type of language unless they bring it up. If, through the work, they find more compassion or empathy toward the person, [that can be a positive outcome], but I just don’t feel that should come from me. It’s not a goal that I would impose on the work,” Crunk says. “There are ways that positive psychology can lead to growth and positive outcomes, but we also have to be careful how we use them. Clients can react, understandably, negatively if they feel their counselor is trying to get them to find beauty in their grief or goodness in their relationship. We have to be careful that it doesn’t feel forced [by] us.”

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Grief and doing your own work

Counselors are human, which means that they will experience personal losses throughout their career. Hearing clients talk about the different painful emotions related to the death of a loved one can be triggering for practitioners if they haven’t fully processed their own feelings regarding a loss in their life.

“It’s hard,” acknowledges Karin Murphy, a licensed professional counselor (LPC) with a practice in Doylestown, Pennsylvania. “Counselors have to do their own work [to process loss]. Oftentimes, counselors are not able to talk about it [a client’s grief or loss] because of their own history. It’s an important component of grief counseling: We have to do our own work so we’re able to let that come into the room.”

Ohio LPC Bernadette Joy Graham recently experienced the death of someone close to her, and she stepped away from her counseling practice for a brief time to mourn and process the loss.

“The counselor really has to have themselves rooted with all of their losses,” Graham says. “No matter how well-trained you are as a grief counselor, grief in your own life will be hard.”

As it relates to counselor grief, the 2014 ACA Code of Ethics cautions against practitioner impairment. Professional counselors are called to “monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when impaired.” See more at counseling.org/knowledge-center/ethics, particularly standards C.2.g. and F.5.b.

 

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Action steps for more information

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.